Provider Demographics
NPI:1215141387
Name:WURTZ, JACKIE K (FNP)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:K
Last Name:WURTZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1365
Mailing Address - Street 2:
Mailing Address - City:HUFFMAN
Mailing Address - State:TX
Mailing Address - Zip Code:77336-1365
Mailing Address - Country:US
Mailing Address - Phone:281-324-1550
Mailing Address - Fax:281-324-1555
Practice Address - Street 1:11515 FM 1960 RD STE C
Practice Address - Street 2:
Practice Address - City:HUFFMAN
Practice Address - State:TX
Practice Address - Zip Code:77336-4431
Practice Address - Country:US
Practice Address - Phone:281-324-1550
Practice Address - Fax:281-324-1555
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX564809363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171697903Medicaid
TX171697903Medicaid